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Tang VM, Yu D, Weissman CR, Jones BDM, Wang G, Sloan ME, Blumberger DM, Daskalakis ZJ, Le Foll B, Voineskos D. Treatment outcomes in major depressive disorder in patients with comorbid alcohol use disorder: A STAR*D analysis. J Affect Disord 2023; 339:691-697. [PMID: 37467796 PMCID: PMC10496139 DOI: 10.1016/j.jad.2023.07.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 06/26/2023] [Accepted: 07/08/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Guidance on Major Depressive Disorder (MDD) treatment in those with comorbid Alcohol Use Disorder (AUD) is limited. We performed a secondary analysis on the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, examining the association between comorbid AUD and depression outcomes. METHODS STAR*D was a real-world effectiveness trial starting with citalopram in level 1. Non-responding participants progressed through 3 other sequential treatment levels with different switch or augmentation options. Antidepressant outcomes were compared between MDD (n = 2826) and comorbid MDD and AUD (n = 864). Logistic regressions were performed to evaluate remission and response predictors in the total STAR*D sample and the AUD-comorbidity interaction. RESULTS Chi-squared tests showed no significant difference in response or remission rates from depression between groups across treatment levels. Higher Hamilton Rating Scale for Depression (HRSD) score was associated with overall lower odds of remission in treatment level 1 (OR = 0.93, p < 0.001) and 2 (OR = 0.95, p < 0.001), with no significant interaction with comorbid AUD. Higher baseline suicidality had overall lower odds of remission in level 1 (OR = 0.82, p < 0.001) and 2 (OR = 0.1, p < 0.001), but with comorbid AUD compared to no AUD, suicidality increased odds of level 1 remission (OR = 1.30, p = 0.012). In comorbid AUD in level 2, venlafaxine was associated with lower odds of remission (OR = 0.13, p = 0.013) and response (OR = 0.12, p = 0.006); bupropion with lower odds of response (OR = 0.22, p = 0.024). LIMITATIONS Open label study design and lack of alcohol use data. CONCLUSIONS Comorbid AUD may interact with predictors of antidepressant response in MDD and using venlafaxine or bupropion may be less effective. Addressing this comorbidity requires unique assessment and treatment approaches.
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Affiliation(s)
- Victor M Tang
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Dengdeng Yu
- Department of Mathematics, University of Texas at Arlington, Arlington, TX, USA
| | - Cory R Weissman
- Department of Psychiatry, UC San Diego Health, La Jolla, CA, USA; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Brett D M Jones
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Guan Wang
- Biostatistics Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Matthew E Sloan
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Daniel M Blumberger
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | | | - Bernard Le Foll
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; Waypoint Research Institute, Waypoint Centre for Mental Health Care, Penetanguishene, ON, Canada
| | - Daphne Voineskos
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Poul Hansen Family Centre for Depression, Krembil Research Institute, Toronto Western Hospital, University Health Network, Canada.
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2
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Affiliation(s)
- Edward V Nunes
- Department of Psychiatry, Division on Substance Use, Columbia University Irving Medical Center and New York State Psychiatric Institute, New York
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3
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Karpyak VM, Coombes BJ, Geske JR, Pazdernik VM, Schneekloth T, Kolla BP, Oesterle T, Loukianova LL, Skime MK, Ho AMC, Ngo Q, Skillon C, Ho MF, Weinshilboum R, Biernacka JM. Genetic predisposition to major depressive disorder differentially impacts alcohol consumption and high-risk drinking situations in men and women with alcohol use disorder. Drug Alcohol Depend 2023; 243:109753. [PMID: 36608483 PMCID: PMC9869363 DOI: 10.1016/j.drugalcdep.2022.109753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/30/2022] [Accepted: 12/15/2022] [Indexed: 12/25/2022]
Abstract
Lifetime history of major depressive disorder (MDD) has a sex-specific association with pretreatment alcohol consumption in patients with alcohol dependence. Here, we investigated the association of genetic load for MDD estimated using a polygenic risk score (PRS) with pretreatment alcohol consumption assessed with Timeline Follow Back in a sample of 287 men and 156 women meeting DSM-IV-TR criteria for alcohol dependence. Preferred drinking situations were assessed using the Inventory of Drug Taking Situations (IDTS). Linear models were used to test for association of normalized alcohol consumption measures with the MDD-PRS, adjusting for ancestry, age, sex, and number of days sober at baseline. We fit models both with and without adjustment for MDD history and alcohol-use-related PRSs as covariates. Higher MDD-PRS was associated with lower 90-day total alcohol consumption in men (β = -0.16, p = 0.0012) but not in women (β = 0.11, p = 0.18). The association of MDD-PRS with IDTS measures was also sex-specific: higher MDD-PRS was associated with higher propensity to drink in temptation-related situations in women, while the opposite (negative association)was found in men. MDD-PRS was not associated with lifetime MDD history in our sample, and adjustment for lifetime MDD and alcohol-related PRSs did not impact the results. Our results suggest that genetic load for MDD impacts pretreatment alcohol consumption in a sex-specific manner, which is similar to, but independent from, the effect of history of MDD. The clinical implications of these findings and contributing biological and psychological factors should be investigated in future studies.
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Affiliation(s)
- Victor M Karpyak
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA; Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA.
| | - Brandon J Coombes
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Jennifer R Geske
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | | | - Terry Schneekloth
- Department of Psychiatry & Psychology, Mayo Clinic, Scottdale, AZ, USA
| | | | - Tyler Oesterle
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
| | | | - Michelle K Skime
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
| | - Ada Man-Choi Ho
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
| | - Quyen Ngo
- Hazelden Betty Ford Foundation, Center City, MN, USA
| | | | - Ming-Fen Ho
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - Richard Weinshilboum
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - Joanna M Biernacka
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA; Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
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4
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Lohoff FW. Targeting Unmet Clinical Needs in the Treatment of Alcohol Use Disorder. Front Psychiatry 2022; 13:767506. [PMID: 35757224 PMCID: PMC9218222 DOI: 10.3389/fpsyt.2022.767506] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 04/29/2022] [Indexed: 11/13/2022] Open
Abstract
Alcohol Use Disorder (AUD) is a chronic psychiatric disorder marked by impaired control over drinking behavior that poses a significant challenge to the individual, their community, the healthcare system and economy. While the negative consequences of chronic excessive alcohol consumption are well-documented, effective treatment for AUD and alcohol-associated diseases remains challenging. Cognitive and behavioral treatment, with or without pharmaceutical interventions, remain the most commonly used methods; however, their efficacy is limited. The development of new treatment protocols for AUD is challenged by difficulty in accurately measuring patterns of alcohol consumption in AUD patients, a lack of a clear understanding of the neuropsychological basis of the disorder, the high likelihood of AUD patients relapsing after receiving treatment, and the numerous end-organ comorbidities associated with excessive alcohol use. Identification and prediction of patients who may respond well to a certain treatment mechanism as well as clinical measurement of a patient's alcohol exposure are bottlenecks in AUD research which should be further addressed. In addition, greater focus must be placed on the development of novel strategies of drug design aimed at targeting the integrated neural pathways implicated in AUD pathogenesis, so that next-generation AUD treatment protocols can address the broad and systemic effects of AUD and its comorbid conditions.
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Affiliation(s)
- Falk W. Lohoff
- Section on Clinical Genomics and Experimental Therapeutics, National Institute on Alcohol Abuse and Alcoholism, NIH, Bethesda, MD, United States
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5
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Fluyau D, Mitra P, Jain A, Kailasam VK, Pierre CG. Selective serotonin reuptake inhibitors in the treatment of depression, anxiety, and post-traumatic stress disorder in substance use disorders: a Bayesian meta-analysis. Eur J Clin Pharmacol 2022; 78:931-942. [PMID: 35246699 DOI: 10.1007/s00228-022-03303-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/21/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Examine SSRIs' efficacy in treating depression, anxiety, PTSD, and substance use in individuals with addiction. METHODS From their inception until August 6, 2021, we searched Google Scholar, PubMed, Scopus, OVID MEDLINE, and Academic Search Complete. We included randomized controlled trials (RCTs) and omitted open-label studies. Bayesian analysis was performed. Bayes factor (BF) established efficacy and tau (τ) statistical heterogeneity. The RoB2 method assessed potential biases. Subgroup analysis was carried out to determine SSRI performance. Treatment duration, SSRI dosage, and attrition rate were all examined in meta-regression. RESULTS We investigated 64 RCTs with 6128 participants. SSRIs reduced depressive symptoms in opioid, alcohol, cocaine, cannabis, and nicotine use disorders (d = 0.353, BF > 99); social anxiety symptoms in alcohol use disorder (d = 0.875, BF > 99); and generalized anxiety symptoms in opioid, alcohol, cocaine, marijuana, and nicotine use disorders (d = 0.346, BF = 4.236). Evidence for PTSD was inconclusive. SSRIs facilitated abstinence for opioid, alcohol, cocaine, cannabis, and nicotine use (d = 0.325, BF > 99); reduced craving for alcohol, cocaine, and nicotine use (d = 0.533, BF = 24.129); and reduced alcohol use (d = 0.452, BF > 99) and cocaine use (d = 0.255, BF = 3.87). Fluoxetine showed the highest antidepressant effect. There was no effect of attrition rate, SSRI dosage, or treatment length on SSRI's efficacy. CONCLUSIONS Results support the use of SSRIs to treat substance use, depression, and anxiety in individuals with addiction. PROTOCOL REGISTRATION PROSPERO registration number: CRD42020164944.
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Affiliation(s)
- Dimy Fluyau
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Dr. NE #200, Atlanta, GA, 30329, USA.
| | - Paroma Mitra
- Department of Psychiatry, NYU Langone Health, New York, NY, USA
| | - Ankit Jain
- Pennsylvania State University, State College, PA, USA
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Donoghue K, Hermann L, Brobbin E, Drummond C. The rates and measurement of adherence to acamprosate in randomised controlled clinical trials: A systematic review. PLoS One 2022; 17:e0263350. [PMID: 35113930 PMCID: PMC8812903 DOI: 10.1371/journal.pone.0263350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 01/17/2022] [Indexed: 12/03/2022] Open
Abstract
AIM The current research aims to systematically review the rates of adherence reported in randomised controlled clinical trials of acamprosate. It also sought to determine the reliability of the adherence monitoring and measurement methods used in these trials. METHODS The protocol for this review was pre-registered (PROSPERO: CRD42021230011). A search of the literature was conducted using OVID MEDLINE, Embase and PsycINFO from database inception to January 2021. Randomised controlled trials with a minimum sample size of 10 per treatment arm that compared the efficacy of acamprosate with placebo or other active medication in adults with a diagnosis of alcohol dependence were included. Data on rates of adherence, methods of measurement and monitoring of adherence was extracted from eligible studies independently in duplicate by two reviewers. A weighted mean adherence rate was calculated. The reliability of adherence monitoring methods was determined by calculating an adherence-assurance score based on the adherence monitoring method used. Risk of bias was assessed using the Cochrane Risk of Bias Tool. RESULTS Fifteen studies met the eligibility criteria involving 4,450 participants (2,480 participants in the placebo arms). A mean adherence rate of 88% (54.2-95.0%) was reported across studies that reported the percentage of medication taken. A mean adherence rate of 84.9% (56.4-91.3%) was reported for trials that reported the percentage of participants taking more than 80% of medication prescribed. There is low confidence in the methods used to monitor adherence with all clinical trials having a low adherence-assurance rating. Risk of bias was judged to be high for all included studies. CONCLUSIONS Adherence to acamprosate in clinical trials can be poor with low confidence in the methods used to measure it. Adherence rates therefore might not be accurate, which has implications for determining the efficacy of acamprosate.
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Affiliation(s)
- Kim Donoghue
- Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom
- National Addictions Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- * E-mail:
| | - Laura Hermann
- National Addictions Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- Institute of Clinical and Applied Health Research, University of Hull, Hull, United Kingdom
| | - Eileen Brobbin
- National Addictions Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Colin Drummond
- National Addictions Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
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7
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Virtanen S, Lagerberg T, Khemiri L, Suvisaari J, Larsson H, Lichtenstein P, Chang Z, Latvala A. Association of selective serotonin re-uptake inhibitor (SSRI) treatment with acute substance misuse outcomes. Addiction 2022; 117:234-242. [PMID: 34185347 DOI: 10.1111/add.15625] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/19/2021] [Accepted: 06/16/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIMS Selective serotonin reuptake inhibitors (SSRIs) are widely prescribed medications for patients with anxiety/depression. These patients often have problems with substance use, but it remains unclear whether the risk of substance misuse is influenced by SSRI treatment. We aimed to determine whether SSRI treatment is associated with a decreased risk of acute substance misuse-related outcomes. DESIGN Cohort study following individuals through Swedish nation-wide registers between July 2005 and December 2013 and comparing the risk of substance misuse outcomes during periods on- versus off-treatment within the same individual. SETTING Swedish general population. PARTICIPANTS Individuals with a newly dispensed prescription of SSRIs between July 2006 and December 2013 and an ICD-10 diagnosis of anxiety/depressive disorder before the first treatment initiation. The cohort included 146 114 individuals (60.7% women). MEASUREMENTS Substance misuse outcomes included ICD-10 diagnoses of acute intoxications (F10.0-F19.0), accidental poisonings by alcohol or drugs (X41-X42, X45-X46) and substance-related criminal offenses. FINDINGS The absolute rate of substance misuse increased sharply before the onset of SSRI treatment and decreased after treatment initiation. Stratified Cox regression models showed an elevated risk [hazard ratio (HR) = 1.70, 95% confidence interval (CI) = 1.62-1.78] of substance misuse outcomes during a 1-month period preceding treatment initiation, compared with the reference period of more than 1 month before treatment start. The on-treatment estimates (1-30 days, HR = 1.29, 95% CI = 1.23-1.37; 31-120 days, HR = 1.30, 95% CI = 1.24-1.35; and > 120 days, HR = 1.24, 95% CI = 1.18-1.30 after treatment initiation] were consistently lower than the 1-month pre-treatment estimate, but still elevated compared with the reference period. CONCLUSIONS For people with anxiety/depression, the risk of substance misuse appears to be particularly elevated immediately before initiating selective serotonin reuptake inhibitor (SSRI) treatment, which may reflect the emergence or worsening of substance use problems concurrently with anxiety/depression. SSRI treatment appears to be associated with a lower risk of substance misuse compared with the 1-month period preceding treatment initiation, but causality remains uncertain.
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Affiliation(s)
- Suvi Virtanen
- Institute of Criminology and Legal Policy, University of Helsinki, Helsinki, Finland.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Tyra Lagerberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Lotfi Khemiri
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Stockholm Health Care Services, County Council, Stockholm, Stockholm, Sweden
| | | | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Paul Lichtenstein
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Antti Latvala
- Institute of Criminology and Legal Policy, University of Helsinki, Helsinki, Finland.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Bareli T, Ahdoot HL, Ben Moshe H, Barnea R, Warhaftig G, Gispan I, Maayan R, Rosca P, Weizman A, Yadid G. Novel Opipramol-Baclofen Combination Alleviates Depression and Craving and Facilitates Recovery From Substance Use Disorder-An Animal Model and a Human Study. Front Behav Neurosci 2021; 15:788708. [PMID: 35002647 PMCID: PMC8733380 DOI: 10.3389/fnbeh.2021.788708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 11/29/2021] [Indexed: 11/13/2022] Open
Abstract
Substance use disorders (SUDs) are associated with depression and anxiety, with the latter being one of the major factors in substance-seeking and relapse. Due to dose-dependent sedative side effects there is limited efficacy of baclofen treatment for SUDs. Here we suggest the use of a novel combination of opipramol and baclofen (O/B) which is known to attenuate anxiety and depression, for the facilitation of recovery from SUDs. Since both opipramol and baclofen have a common downstream signal transduction, their individual doses could be reduced while still maintaining the benefits of the combination. We tested the O/B combination in both animals and patients. Rats treated with O/B showed significant attenuation in craving behavior and in relapse rate during withdrawal from cocaine. In a double-blind, placebo-controlled pilot study, conducted in a residential detoxification center, 14 males and 3 females, aged 28-60 years were assigned to a study (n = 6) and a placebo (n = 11) group (placebo group: 40 ± 10.5 years; O/B group 40 ± 10.8 years). The participants completed scales measuring depression, anxiety and craving symptoms and provided saliva samples for stress hormone examination [cortisol and dehydroepiandrosterone-sulfate (DHEA-S)]. Participants with polysubstance use disorder (PsUD) treated with O/B showed a reduction in cravings and depression and an increase in DHEA-S and in the DHEA-S/cortisol ratio. Our findings indicate a beneficial effect of O/B treatment. This study suggests a novel candidate for pharmacological treatment of patients with SUD and comorbid mood/anxiety disorders that may facilitate their rehabilitation.
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Affiliation(s)
- Tzofnat Bareli
- Faculty of Life Sciences, Leslie and Gonda (Goldschmied) Multidisciplinary Brain Research Center, Bar Ilan University, Ramat Gan, Israel
| | - Hadas Levi Ahdoot
- Faculty of Life Sciences, Leslie and Gonda (Goldschmied) Multidisciplinary Brain Research Center, Bar Ilan University, Ramat Gan, Israel
| | - Hila Ben Moshe
- Faculty of Life Sciences, Leslie and Gonda (Goldschmied) Multidisciplinary Brain Research Center, Bar Ilan University, Ramat Gan, Israel
| | - Royi Barnea
- Faculty of Life Sciences, Leslie and Gonda (Goldschmied) Multidisciplinary Brain Research Center, Bar Ilan University, Ramat Gan, Israel
| | - Gal Warhaftig
- Faculty of Life Sciences, Leslie and Gonda (Goldschmied) Multidisciplinary Brain Research Center, Bar Ilan University, Ramat Gan, Israel
| | - Iris Gispan
- Faculty of Life Sciences, Leslie and Gonda (Goldschmied) Multidisciplinary Brain Research Center, Bar Ilan University, Ramat Gan, Israel
| | - Rachel Maayan
- The Laboratory of Molecular Psychiatry, Felsenstein Medical Research Center, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Paola Rosca
- Department for the Treatment of Substance Abuse and Mental Health Services, Israeli Ministry of Health, Jerusalem, Israel
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Abraham Weizman
- The Laboratory of Molecular Psychiatry, Felsenstein Medical Research Center, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Research Unit, Geha Mental Health Center, Petah Tikva, Israel
| | - Gal Yadid
- Faculty of Life Sciences, Leslie and Gonda (Goldschmied) Multidisciplinary Brain Research Center, Bar Ilan University, Ramat Gan, Israel
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Stokes PRA, Jokinen T, Amawi S, Qureshi M, Husain MI, Yatham LN, Strang J, Young AH. Pharmacological Treatment of Mood Disorders and Comorbid Addictions: A Systematic Review and Meta-Analysis: Traitement Pharmacologique des Troubles de L'humeur et des Dépendances Comorbides: Une Revue Systématique et une Méta-Analyse. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2020; 65:749-769. [PMID: 32302221 PMCID: PMC7564307 DOI: 10.1177/0706743720915420] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Addiction comorbidity is an important clinical challenge in mood disorders, but the best way of pharmacologically treating people with mood disorders and addictions remains unclear. The aim of this study was to assess the efficacy of pharmacological treatments for mood and addiction symptoms in people with mood disorders and addiction comorbidity. METHODS A systematic search of placebo-controlled randomized controlled trials investigating the effects of pharmacological treatments in people with bipolar disorder (BD) or major depressive disorder (MDD), and comorbid addictions was performed. Treatment-related effects on mood and addiction measures were assessed in a meta-analysis, which also estimated risks of participant dropout and adverse effects. RESULTS A total of 32 studies met systematic review inclusion criteria. Pharmacological therapy was more effective than placebo for improving manic symptoms (standardized mean difference [SMD] = -0.15; 95% confidence interval [95% CI], -0.29 to -0.02; P = 0.03) but not BD depressive symptoms (SMD = -0.09; 95% CI, -0.22 to 0.03; P = 0.15). Quetiapine significantly improved manic symptoms (SMD = -0.23; 95% CI, -0.39 to -0.06; P = 0.008) but not BD depressive symptoms (SMD = -0.07; 95% CI, -0.23 to 0.10; P = 0.42). Pharmacological therapy was more effective than placebo for improving depressive symptoms in MDD (SMD = -0.16; 95% CI, -0.30 to -0.03; P = 0.02). Imipramine improved MDD depressive symptoms (SMD = -0.58; 95% CI, -1.03 to -0.13; P = 0.01) but Selective serotonin reuptake Inhibitors (SSRI)-based treatments had no effect (SMD = -0.06; 95% CI, -0.30 to 0.17; P = 0.60). Pharmacological treatment improved the odds of alcohol abstinence in MDD but had no effects on opiate abstinence. CONCLUSIONS Pharmacological treatments were significantly better than placebo in improving manic symptoms, MDD depressive symptoms, and alcohol abstinence but were not better for bipolar depression symptoms. Importantly, quetiapine was not more effective than placebo in improving bipolar depression symptoms nor were SSRI's for the treatment of MDD depression. Our findings highlight the need for further high-quality clinical trials of treatments for mood disorders and comorbid addictions.
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Affiliation(s)
- Paul R A Stokes
- Department of Psychological Medicine, Centre for Affective Disorders, 34426Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom.,South London and Maudsley NHS Foundation Trust, Beckenham, Kent, United Kingdom.,National Institute for Health Research (NIHR) Maudsley Biomedical Research Centre (BRC) at South London Maudsley Foundation Trust and King's College London, United Kingdom
| | - Tahir Jokinen
- Department of Psychological Medicine, Centre for Affective Disorders, 34426Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
| | - Sami Amawi
- Department of Psychological Medicine, Centre for Affective Disorders, 34426Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
| | - Mutahira Qureshi
- South London and Maudsley NHS Foundation Trust, Beckenham, Kent, United Kingdom
| | - Muhammad Ishrat Husain
- Department of Psychiatry, University of Toronto, Canada.,Centre for Addiction and Mental Health, Toronto, Canada
| | | | - John Strang
- National Institute for Health Research (NIHR) Maudsley Biomedical Research Centre (BRC) at South London Maudsley Foundation Trust and King's College London, United Kingdom.,Department of Addictions, 34426Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
| | - Allan H Young
- Department of Psychological Medicine, Centre for Affective Disorders, 34426Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom.,South London and Maudsley NHS Foundation Trust, Beckenham, Kent, United Kingdom.,National Institute for Health Research (NIHR) Maudsley Biomedical Research Centre (BRC) at South London Maudsley Foundation Trust and King's College London, United Kingdom
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10
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Lohoff FW. Pharmacotherapies and personalized medicine for alcohol use disorder: a review. Pharmacogenomics 2020; 21:1117-1138. [PMID: 32807012 DOI: 10.2217/pgs-2020-0079] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Alcohol use disorder (AUD) is highly prevalent and among the leading causes of morbidity and mortality in the United States. Pharmacotherapies for AUD are limited, thus making identification of patient subgroups that are most likely to respond favorably crucial. In this article, pharmacogenetic research on US FDA-approved and commonly prescribed off-label medications for the treatment of AUD is comprehensively reviewed. While the field has advanced in understanding pharmacotherapies for AUD and potential genetic moderators of treatment responses, the pharmacogenetic data to guide the prescribing clinician are limited and should be interpreted with caution. Precision medicine for AUD with more beneficial treatment responses and minimal side effects remains a high priority for further research.
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Affiliation(s)
- Falk W Lohoff
- Section on Clinical Genomics & Experimental Therapeutics, National Institute on Alcohol Abuse & Alcoholism, NIH, Bethesda, MD 20892-1540, USA
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Li J, Wang H, Li M, Shen Q, Li X, Rong X, Peng Y. Efficacy of pharmacotherapeutics for patients comorbid with alcohol use disorders and depressive symptoms-A bayesian network meta-analysis. CNS Neurosci Ther 2020; 26:1185-1197. [PMID: 32686291 PMCID: PMC7564195 DOI: 10.1111/cns.13437] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/25/2020] [Accepted: 06/28/2020] [Indexed: 12/05/2022] Open
Abstract
Background We aimed to compare and rank the efficacy of different pharmacotherapeutics for patients comorbid with alcohol use disorders and depressive symptoms. Method Bayesian network meta‐analysis was performed for three different outcome parameters: alcohol use disorders (AUD) remission rate, percent abstinent days, and scores of depression scales. The surface under the cumulative ranking curves (SUCRA) was used for ranking the efficacy of interventions. Sensitivity analysis and direct pairwise analysis were conducted to validate the main results. Results A total of 68 RCTs consisting of 5890 patients were included. Disulfiram could significantly increase the AUD remission rates (OR 5.02, 1.97‐12.95) and the percent abstinent days (MD 17.08, 3.48‐30.93). Disulfiram was associated with the best efficacy in achieving remission (SUCRA 95.1%) and increasing abstinent days (SUCRA 87.6%). Noradrenaline reuptake inhibitor was significantly more efficacious than controls (SMD −2.44, −3.53 to −1.36) and have the first rank (SUCRA 99.0%) in reducing the scores of depression scales. Antiepileptics have relatively higher ranks in efficacy for both AUD and depressive symptoms. Conclusions Disulfiram was associated with the best efficacy in achieving abstinence for comorbidity patients. Noradrenaline reuptake inhibitor was demonstrated to be associated with the best efficacy in reducing scores of depression scales. Antiepileptics might be beneficial to both alcohol‐related and depressive symptoms.
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Affiliation(s)
- Jiande Li
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Hongxuan Wang
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Mei Li
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Qingyu Shen
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xiangpen Li
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xiaoming Rong
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ying Peng
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumour Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
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Hillemacher T, Frieling H. Pharmacotherapeutic options for co-morbid depression and alcohol dependence. Expert Opin Pharmacother 2019; 20:547-569. [DOI: 10.1080/14656566.2018.1561870] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Thomas Hillemacher
- Department of Psychiatry and Psychotherapy, Paracelsus Medical University, Nuremberg, Germany
| | - Helge Frieling
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
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Multiple possible inaccuracies cast doubt on a recent report suggesting selective serotonin reuptake inhibitors to be toxic and ineffective. Acta Neuropsychiatr 2018; 30:244-250. [PMID: 28718394 DOI: 10.1017/neu.2017.23] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
According to a systematic review on the use of selective serotonin reuptake inhibitors (SSRIs) in adult depression that was recently published in BMC Psychiatry, the results of which have been widely disseminated in lay media, these drugs increase the risk for serious adverse events (SAEs) while exerting poor antidepressant efficacy. A cursory analysis, however, suggests the analysis of SAEs conducted by the authors to be marred by both methodological inaccuracies and blatant errors. After having corrected for these apparent mistakes, we conducted a sensitivity analysis in which we also accounted for a possible moderating effect of age; while this suggests SSRIs to be safe drugs in the non-elderly, they do confirm what is already known, that is, that they may enhance the risk for SAEs in the old. Given the loose definition of SAE, including also innocuous phenomena, the possible clinical significance of the latter observation, however, remains unclear until the nature and actual impact of the SAEs in question have been clarified. Moreover, with respect to efficacy, we find the paper in BMC Psychiatry misleading: first, the authors seem unaware of the well-established shortcomings associated with the conventional efficacy parameter on which their analysis is based, second, they have included suboptimal SSRI doses and third, they have missed some pivotal trials. Unless there are explanations for the many peculiarities in this paper that have escaped us, and which may be satisfactorily clarified by the authors, it seems important that the conclusions presented in this paper be publicly rectified.
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Katakam and co-workers have not shown SSRIs to be harmful and ineffective and should stop claiming that they have. Acta Neuropsychiatr 2018; 30:266-274. [PMID: 30022741 DOI: 10.1017/neu.2018.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Funded by the Danish state to provide guidance in health-related matters, the Copenhagen Trial Unit (CTU) at Rigshospitalet may cause considerable societal harm if allowing their analyses to be influenced by bias and prejudice rather than rigor and impartiality. This is why we found it worthwhile to comment on a report from the CTU in which the authors invoked analyses marred by numerous errors and methodological mistakes to claim that selective serotonin reuptake inhibitors (SSRIs) are harmful and ineffective. The CTU group has now produced a response to our comment which is on par with their original contribution in terms of bias, misconceptions and mistakes. Our conclusion is that the reputation of the CTU would be best served by the authors asking for retraction of their SSRI paper.
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Great boast, small roast on effects of selective serotonin reuptake inhibitors: response to a critique of our systematic review. Acta Neuropsychiatr 2018; 30:251-265. [PMID: 29465026 DOI: 10.1017/neu.2017.38] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Our systematic review in BMC Psychiatry concluded that selective serotonin reuptake inhibitors (SSRIs) compared with placebo significantly increase the risk of serious adverse events (SAEs) in patients with major depression and the potential beneficial effects of SSRIs seem to be outweighed by the harms. Hieronymus et al. accused us of methodological inaccuracies and blatant errors. In their post-hoc analysis of our data, they reported that SSRIs only increase the risk of SAEs in elderly and seems safe for non-elderly patients. They also found our review misleading because our efficacy analyses were based on the 17-item Hamilton Depression Rating Scale; we included suboptimal SSRI doses; and we missed some 'pivotal trials'. We do not agree with Hieronymus et al. regarding several of the 'errors' they claim that we have made. However, we acknowledge that they have identified minor errors and that we missed some trials. After rectifying the errors and inclusion of the missed trials by us and Hieronymus et al., we re-analysed the data. The updated analyses are even more robust and confirm our earlier conclusions. SSRIs significantly increase the risk of an SAE both in non-elderly (p=0.045) and elderly (p=0.01) patients [overall odds ratio 1.39; 95% confidence interval (CI) 1.13 to 1.73; p=0.002; I2=0%]. Moreover, SSRIs did not change noticeably the 17-item Hamilton Depression Rating Scale, the internationally accepted scale (mean difference -2.02 points; 95% CI -2.38 to -1.66; p<0.00001). We found no differential effect of dose (p=0.20).
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Samokhvalov AV, Probst C, Awan S, George TP, Le Foll B, Voore P, Rehm J. Outcomes of an integrated care pathway for concurrent major depressive and alcohol use disorders: a multisite prospective cohort study. BMC Psychiatry 2018; 18:189. [PMID: 29898697 PMCID: PMC6001012 DOI: 10.1186/s12888-018-1770-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 05/29/2018] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND In 2013, an Integrated Care Pathway (ICP) for concurrent Major Depressive (MDD) and Alcohol Use (AUD) Disorders was developed at the Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada. The ICP was further implemented at 8 other clinical sites across Ontario (the DA VINCI Project) in 2015-2017. The goal of this study was to systematically describe and analyze the main clinical outcomes of the project. METHODS Data on a non-randomized cohort of patients receiving ICP-based treatment were collected prospectively at nine clinical sites in a variety of clinical settings. STATISTICAL METHODS descriptive statistics, t-test, chi-square, ANOVA, generalized linear models. RESULTS Two hundred forty-six patients were enrolled, 58.8% males, mean age was 45.6 years, 170 patients received treatment at academic health centres (AHC), 49 - at community hospitals (CH) and 27 - in family health teams (FHT). There were no major differences in anamnestic parameters and depression severity between the three settings, but there were differences in baseline drinking patterns between subgroups (F = 4.271, df = 2, p = 0.015). Overall completion rate was 70.7% with no significant variation between settings (χ2 = 3.35, df = 2, p = 0.19). Treatment duration in AHC was the longest, and completion rates were the highest. There was a statistically significant and clinically meaningful reduction in the number of drinking days per week (1.81, t = 8.78, p < 0.001). The cohort overall demonstrated significant and meaningful reduction in severity of cravings (Penn Alcohol Craving Scale: 4.42, t = 8.63, p < 0.001) and depressive symptoms (Quick Inventory of Depressive Symptomatology: 4.25, t = 11.26, p < 0.001). While some of the baseline patient characteristics and treatment parameters varied between the settings, the variation in clinical outcomes was mostly insignificant, though clinical improvement was more pronounced in academic setting and with individual therapy. CONCLUSIONS The study demonstrated that ICP is a feasible and effective treatment for concurrent AUD and MDD that delivers meaningful clinical improvement in a variety of settings. A randomized controlled study is needed to properly compare the treatment outcomes between ICP model and treatment as usual and to further explore the role of various factors on treatment outcomes.
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Affiliation(s)
- Andriy V. Samokhvalov
- 0000 0000 8793 5925grid.155956.bAddictions Division, Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Office T519, Toronto, ON M5S 2S1 Canada ,0000 0001 2157 2938grid.17063.33Institute for Medical Science, University of Toronto, Toronto, ON Canada ,0000 0000 8793 5925grid.155956.bInstitute for Mental Health Policy Research, CAMH, Toronto, ON Canada ,0000 0001 2157 2938grid.17063.33Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto, Toronto, ON Canada
| | - Charlotte Probst
- 0000 0000 8793 5925grid.155956.bInstitute for Mental Health Policy Research, CAMH, Toronto, ON Canada ,0000 0001 2111 7257grid.4488.0Institute for Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Sachsen Germany ,WHO Collaborating Centre on Mental Health and Addiction, Toronto, ON Canada
| | - Saima Awan
- 0000 0000 8793 5925grid.155956.bAddictions Division, Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Office T519, Toronto, ON M5S 2S1 Canada
| | - Tony P. George
- 0000 0000 8793 5925grid.155956.bAddictions Division, Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Office T519, Toronto, ON M5S 2S1 Canada ,0000 0001 2157 2938grid.17063.33Institute for Medical Science, University of Toronto, Toronto, ON Canada ,0000 0001 2157 2938grid.17063.33Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto, Toronto, ON Canada
| | - Bernard Le Foll
- 0000 0000 8793 5925grid.155956.bAddictions Division, Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Office T519, Toronto, ON M5S 2S1 Canada ,0000 0001 2157 2938grid.17063.33Institute for Medical Science, University of Toronto, Toronto, ON Canada ,0000 0000 8793 5925grid.155956.bInstitute for Mental Health Policy Research, CAMH, Toronto, ON Canada ,0000 0001 2157 2938grid.17063.33Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto, Toronto, ON Canada ,0000 0000 8793 5925grid.155956.bCampbell Family Mental Health Research Institute, Toronto, ON Canada
| | - Peter Voore
- 0000 0000 8793 5925grid.155956.bAddictions Division, Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Office T519, Toronto, ON M5S 2S1 Canada ,0000 0001 2157 2938grid.17063.33Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto, Toronto, ON Canada
| | - Jürgen Rehm
- 0000 0000 8793 5925grid.155956.bAddictions Division, Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Office T519, Toronto, ON M5S 2S1 Canada ,0000 0001 2157 2938grid.17063.33Institute for Medical Science, University of Toronto, Toronto, ON Canada ,0000 0000 8793 5925grid.155956.bInstitute for Mental Health Policy Research, CAMH, Toronto, ON Canada ,0000 0001 2157 2938grid.17063.33Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto, Toronto, ON Canada ,0000 0000 8793 5925grid.155956.bCampbell Family Mental Health Research Institute, Toronto, ON Canada ,0000 0001 2157 2938grid.17063.33Division of Adult Psychiatry and Health Systems, Department of Psychiatry, University of Toronto, Toronto, ON Canada ,0000 0001 2157 2938grid.17063.33Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada ,0000 0001 2111 7257grid.4488.0Institute for Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Sachsen Germany ,WHO Collaborating Centre on Mental Health and Addiction, Toronto, ON Canada
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Pharmacological and Psychological Treatments for Comorbid Alcohol Use Disorder and Depressive Disorder: a Review. CURRENT ADDICTION REPORTS 2018. [DOI: 10.1007/s40429-018-0213-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Agabio R, Trogu E, Pani PP. Antidepressants for the treatment of people with co-occurring depression and alcohol dependence. Cochrane Database Syst Rev 2018; 4:CD008581. [PMID: 29688573 PMCID: PMC6494437 DOI: 10.1002/14651858.cd008581.pub2] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Alcohol dependence is a major public health problem characterized by recidivism, and medical and psychosocial complications. The co-occurrence of major depression in people entering treatment for alcohol dependence is common, and represents a risk factor for morbidity and mortality, which negatively influences treatment outcomes. OBJECTIVES To assess the benefits and risks of antidepressants for the treatment of people with co-occurring depression and alcohol dependence. SEARCH METHODS We searched the Cochrane Drugs and Alcohol Group Specialised Register (via CRSLive), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase from inception to July 2017. We also searched for ongoing and unpublished studies via ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (apps.who.int/trialsearch/).All searches included non-English language literature. We handsearched references of topic-related systematic reviews and the included studies. SELECTION CRITERIA Randomized controlled trials and controlled clinical trials comparing antidepressants alone or in association with other drugs or psychosocial interventions (or both) versus placebo, no treatment, and other pharmacological or psychosocial interventions. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by Cochrane. MAIN RESULTS We included 33 studies in the review (2242 participants). Antidepressants were compared to placebo (22 studies), psychotherapy (two studies), other medications (four studies), or other antidepressants (five studies). The mean duration of the trials was 9.9 weeks (range 3 to 26 weeks). Eighteen studies took place in the USA, 12 in Europe, two in Turkey, and one in Australia. The antidepressant included in most of the trials was sertraline; other medications were amitriptyline, citalopram, desipramine, doxepin, escitalopram, fluoxetine, fluvoxamine, imipramine, mianserin, mirtazepine, nefazodone, paroxetine, tianeptine, venlafaxine, and viloxazine. Eighteen studies were conducted in an outpatient setting, nine in an inpatient setting, and six in both settings. Psychosocial treatment was provided in 18 studies. There was high heterogeneity in the selection of outcomes and the rating systems used for diagnosis and outcome assessment.Comparing antidepressants to placebo, low-quality evidence suggested that antidepressants reduced the severity of depression evaluated with interviewer-rated scales at the end of trial (14 studies, 1074 participants, standardized mean difference (SMD) -0.27, 95% confidence interval (CI) -0.49 to -0.04). However, the difference became non-significant after the exclusion of studies with a high risk of bias (SMD -0.17, 95% CI -0.39 to 0.04). In addition, very low-quality evidence supported the efficacy of antidepressants in increasing the response to the treatment (10 studies, 805 participants, risk ratio (RR) 1.40, 95% Cl 1.08 to 1.82). This result became non-significant after the exclusion of studies at high risk of bias (RR 1.27, 95% CI 0.96 to 1.68). There was no difference for other relevant outcomes such as the difference between baseline and final score, evaluated using interviewer-rated scales (5 studies, 447 participants, SMD 0.15, 95% CI -0.12 to 0.42).Moderate-quality evidence found that antidepressants increased the number of participants abstinent from alcohol during the trial (7 studies, 424 participants, RR 1.71, 95% Cl 1.22 to 2.39) and reduced the number of drinks per drinking days (7 studies, 451 participants, mean difference (MD) -1.13 drinks per drinking days, 95% Cl -1.79 to -0.46). After the exclusion of studies with high risk of bias, the number of abstinent remained higher (RR 1.69, 95% CI 1.18 to 2.43) and the number of drinks per drinking days lower (MD -1.21 number of drinks per drinking days, 95% CI -1.91 to -0.51) among participants who received antidepressants compared to those who received placebo. However, other outcomes such as the rate of abstinent days did not differ between antidepressants and placebo (9 studies, 821 participants, MD 1.34, 95% Cl -1.66 to 4.34; low-quality evidence).Low-quality evidence suggested no differences between antidepressants and placebo in the number of dropouts (17 studies, 1159 participants, RR 0.98, 95% Cl 0.79 to 1.22) and adverse events as withdrawal for medical reasons (10 studies, 947 participants, RR 1.15, 95% Cl 0.65 to 2.04).There were few studies comparing one antidepressant versus another antidepressant or antidepressants versus other interventions, and these had a small sample size and were heterogeneous in terms of the types of interventions that were compared, yielding results that were not informative. AUTHORS' CONCLUSIONS We found low-quality evidence supporting the clinical use of antidepressants in the treatment of people with co-occurring depression and alcohol dependence. Antidepressants had positive effects on certain relevant outcomes related to depression and alcohol use but not on other relevant outcomes. Moreover, most of these positive effects were no longer significant when studies with high risk of bias were excluded. Results were limited by the large number of studies showing high or unclear risk of bias and the low number of studies comparing one antidepressant to another or antidepressants to other medication. In people with co-occurring depression and alcohol dependence, the risk of developing adverse effects appeared to be minimal, especially for the newer classes of antidepressants (such as selective serotonin reuptake inhibitors). According to these results, in people with co-occurring depression and alcohol dependence, antidepressants may be useful for the treatment of depression, alcohol dependence, or both, although the clinical relevance may be modest.
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Affiliation(s)
- Roberta Agabio
- University of CagliariDepartment of Biomedical Sciences, Section of Neuroscience and Clinical PharmacologyCagliariItaly
| | - Emanuela Trogu
- Cagliari Public Health TrustDepartment of PsychiatryASL CagliariCagliariSardiniaItaly09128
| | - Pier Paolo Pani
- Sardinia Protection Health TrustSassari Social‐Health AreaSassariSardiniaItaly
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Glass-Box Testing the Centre for Addiction and Mental Health Integrated Care Pathway for Major Depressive and Alcohol Use Disorders: Is It More Than a Sum of Its Components? CANADIAN JOURNAL OF ADDICTION 2018. [DOI: 10.1097/cxa.0000000000000011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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20
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Samokhvalov AV, Awan S, George TP, Irving J, Le Foll B, Perrotta S, Probst C, Voore P, Rehm J. Integrated care pathway for co-occurring major depressive and alcohol use disorders: Outcomes of the first two years. Am J Addict 2017; 26:602-609. [PMID: 28570773 DOI: 10.1111/ajad.12572] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 03/30/2017] [Accepted: 05/11/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Major Depressive Disorder (MDD) and Alcohol Use Disorder (AUD) are highly prevalent, comorbid, and have significant impact on morbidity, mortality, and socioeconomic burden in Canada. Combined psycho- and pharmacotherapies for both conditions promise better outcomes than treatment as usual (TAU). At the Centre for Addiction and Mental Health, Toronto, Canada, we developed and implemented an Integrated Care Pathway (ICP) specifically for treatment of concurrent MDD and AUD. The goal of the study is to assess the clinical effectiveness of the ICP approach in comparison to TAU. MATERIALS AND METHODS Non-randomized design, clinical chart review, Chi-square and t-tests, Cohen's d, Linear Mixed Effects Models, Kaplan-Meier, and log-rank analyses. RESULTS Eighty-one ICP patients were included, matched to 81 controls by age, sex, severity of depressive symptoms, and patterns of drinking. ICP cohort had a significantly lower dropout rate (18.5% vs 69.1%, p < .001; at 16 weeks of treatment, respectively), both cohorts demonstrated significant reduction in the number of heavy drinking days (β = .01, p < .001) and standard drinks per week (β = .15, p < .001) with a significantly higher reduction of both indicators over time in the ICP cohort. Significant reduction in depressive symptoms severity (QIDS: 14.6 vs 10.0, p < .001; BDI: 26.3 vs 16.2, p < .001) was observed in ICP cohort (no data for TAU cohort). CONCLUSIONS The ICP patients demonstrated improvements on several levels including depressive symptoms, and changes in alcohol drinking patterns. The study demonstrated the overall effectiveness of the ICP and apparent advantage over TAU, which must be corroborated through a randomized clinical trial. (Am J Addict 2017;26:602-609) SCIENTIFIC SIGNIFICANCE: This study is one of the first works showing the outcomes of an ICP developed in the mental health area and for co-occurring disorders. Despite the limitations, the relative advantage of the ICP methodology warrants future research in this area.
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Affiliation(s)
- Andriy V Samokhvalov
- Addictions Division, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.,Institute for Mental Health Policy Research, CAMH, Toronto, Ontario, Canada.,Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Saima Awan
- Addictions Division, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada
| | - Tony P George
- Addictions Division, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.,Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Julie Irving
- Addictions Division, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada
| | - Bernard Le Foll
- Addictions Division, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.,Institute for Mental Health Policy Research, CAMH, Toronto, Ontario, Canada.,Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Campbell Family Mental Health Research Institute, Toronto, Ontario, Canada
| | - Steve Perrotta
- Addictions Division, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada
| | - Charlotte Probst
- Institute for Mental Health Policy Research, CAMH, Toronto, Ontario, Canada.,Institute for Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Sachsen, Germany.,WHO Collaborating Centre on Mental Health and Addiction, Toronto, Ontario, Canada
| | - Peter Voore
- Addictions Division, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada.,Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Jürgen Rehm
- Addictions Division, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.,Institute for Mental Health Policy Research, CAMH, Toronto, Ontario, Canada.,Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Campbell Family Mental Health Research Institute, Toronto, Ontario, Canada.,Division of Adult Psychiatry and Health Systems, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health (DLSPH), University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Sachsen, Germany.,WHO Collaborating Centre on Mental Health and Addiction, Toronto, Ontario, Canada
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Soyka M, Kranzler HR, Hesselbrock V, Kasper S, Mutschler J, Möller HJ. Guidelines for biological treatment of substance use and related disorders, part 1: Alcoholism, first revision. World J Biol Psychiatry 2017; 18:86-119. [PMID: 28006997 DOI: 10.1080/15622975.2016.1246752] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
These practice guidelines for the biological treatment of alcohol use disorders are an update of the first edition, published in 2008, which was developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). For this 2016 revision, we performed a systematic review (MEDLINE/PUBMED database, Cochrane Library) of all available publications pertaining to the biological treatment of alcoholism and extracted data from national guidelines. The Task Force evaluated the identified literature with respect to the strength of evidence for the efficacy of each medication and subsequently categorised it into six levels of evidence (A-F) and five levels of recommendation (1-5). Thus, the current guidelines provide a clinically and scientifically relevant, evidence-based update of our earlier recommendations. These guidelines are intended for use by clinicians and practitioners who evaluate and treat people with alcohol use disorders and are primarily concerned with the biological treatment of adults with such disorders.
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Affiliation(s)
- Michael Soyka
- a Psychiatric Hospital Meiringen , Meiringen , Switzerland.,b Department of Psychiatry , Ludwig-Maximilians-University , Munich , Germany.,c Medicalpark Chiemseeblick , Bernau , Germany
| | - Henry R Kranzler
- d Crescenz VAMC , University of Pennsylvania and VISN 4 MIRECC , Philadelphia , PA , USA
| | | | - Siegfried Kasper
- f Department of Psychiatric Medicine , University of Vienna, Vienna , Austria
| | - Jochen Mutschler
- a Psychiatric Hospital Meiringen , Meiringen , Switzerland.,g Psychiatric Hospital University of Zürich, Zürich , Switzerland
| | - Hans-Jürgen Möller
- b Department of Psychiatry , Ludwig-Maximilians-University , Munich , Germany
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22
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Jakobsen JC, Katakam KK, Schou A, Hellmuth SG, Stallknecht SE, Leth-Møller K, Iversen M, Banke MB, Petersen IJ, Klingenberg SL, Krogh J, Ebert SE, Timm A, Lindschou J, Gluud C. Selective serotonin reuptake inhibitors versus placebo in patients with major depressive disorder. A systematic review with meta-analysis and Trial Sequential Analysis. BMC Psychiatry 2017; 17:58. [PMID: 28178949 PMCID: PMC5299662 DOI: 10.1186/s12888-016-1173-2] [Citation(s) in RCA: 183] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 12/20/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The evidence on selective serotonin reuptake inhibitors (SSRIs) for major depressive disorder is unclear. METHODS Our objective was to conduct a systematic review assessing the effects of SSRIs versus placebo, 'active' placebo, or no intervention in adult participants with major depressive disorder. We searched for eligible randomised clinical trials in The Cochrane Library's CENTRAL, PubMed, EMBASE, PsycLIT, PsycINFO, Science Citation Index Expanded, clinical trial registers of Europe and USA, websites of pharmaceutical companies, the U.S. Food and Drug Administration (FDA), and the European Medicines Agency until January 2016. All data were extracted by at least two independent investigators. We used Cochrane systematic review methodology, Trial Sequential Analysis, and calculation of Bayes factor. An eight-step procedure was followed to assess if thresholds for statistical and clinical significance were crossed. Primary outcomes were reduction of depressive symptoms, remission, and adverse events. Secondary outcomes were suicides, suicide attempts, suicide ideation, and quality of life. RESULTS A total of 131 randomised placebo-controlled trials enrolling a total of 27,422 participants were included. None of the trials used 'active' placebo or no intervention as control intervention. All trials had high risk of bias. SSRIs significantly reduced the Hamilton Depression Rating Scale (HDRS) at end of treatment (mean difference -1.94 HDRS points; 95% CI -2.50 to -1.37; P < 0.00001; 49 trials; Trial Sequential Analysis-adjusted CI -2.70 to -1.18); Bayes factor below predefined threshold (2.01*10-23). The effect estimate, however, was below our predefined threshold for clinical significance of 3 HDRS points. SSRIs significantly decreased the risk of no remission (RR 0.88; 95% CI 0.84 to 0.91; P < 0.00001; 34 trials; Trial Sequential Analysis adjusted CI 0.83 to 0.92); Bayes factor (1426.81) did not confirm the effect). SSRIs significantly increased the risks of serious adverse events (OR 1.37; 95% CI 1.08 to 1.75; P = 0.009; 44 trials; Trial Sequential Analysis-adjusted CI 1.03 to 1.89). This corresponds to 31/1000 SSRI participants will experience a serious adverse event compared with 22/1000 control participants. SSRIs also significantly increased the number of non-serious adverse events. There were almost no data on suicidal behaviour, quality of life, and long-term effects. CONCLUSIONS SSRIs might have statistically significant effects on depressive symptoms, but all trials were at high risk of bias and the clinical significance seems questionable. SSRIs significantly increase the risk of both serious and non-serious adverse events. The potential small beneficial effects seem to be outweighed by harmful effects. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42013004420.
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Affiliation(s)
- Janus Christian Jakobsen
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812 Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Rigshospitalet, DK 2100 Copenhagen, Denmark
- Department of Cardiology, Holbæk Hospital, Holbæk, Denmark
| | - Kiran Kumar Katakam
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812 Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Rigshospitalet, DK 2100 Copenhagen, Denmark
| | - Anne Schou
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812 Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Rigshospitalet, DK 2100 Copenhagen, Denmark
| | - Signe Gade Hellmuth
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812 Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Rigshospitalet, DK 2100 Copenhagen, Denmark
| | - Sandra Elkjær Stallknecht
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812 Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Rigshospitalet, DK 2100 Copenhagen, Denmark
| | - Katja Leth-Møller
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812 Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Rigshospitalet, DK 2100 Copenhagen, Denmark
| | - Maria Iversen
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812 Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Rigshospitalet, DK 2100 Copenhagen, Denmark
| | - Marianne Bjørnø Banke
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812 Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Rigshospitalet, DK 2100 Copenhagen, Denmark
| | - Iggiannguaq Juhl Petersen
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812 Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Rigshospitalet, DK 2100 Copenhagen, Denmark
| | - Sarah Louise Klingenberg
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812 Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Rigshospitalet, DK 2100 Copenhagen, Denmark
| | - Jesper Krogh
- Mental Health Centre Copenhagen, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sebastian Elgaard Ebert
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812 Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Rigshospitalet, DK 2100 Copenhagen, Denmark
| | - Anne Timm
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812 Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Rigshospitalet, DK 2100 Copenhagen, Denmark
| | - Jane Lindschou
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812 Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Rigshospitalet, DK 2100 Copenhagen, Denmark
| | - Christian Gluud
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812 Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Rigshospitalet, DK 2100 Copenhagen, Denmark
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Tolliver BK, Anton RF. Assessment and treatment of mood disorders in the context of substance abuse. DIALOGUES IN CLINICAL NEUROSCIENCE 2016. [PMID: 26246792 PMCID: PMC4518701 DOI: 10.31887/dcns.2015.17.2/btolliver] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Recognition and management of mood symptoms in individuals using alcohol and/or other drugs represent a daily challenge for clinicians in both inpatient and outpatient treatment settings. Diagnosis of underlying mood disorders in the context of ongoing substance abuse requires careful collection of psychiatric history, and is often critical for optimal treatment planning and outcomes. Failure to recognize major depression or bipolar disorders in these patients can result in increased relapse rates, recurrence of mood episodes, and elevated risk of completed suicide. Over the past decade, epidemiologic research has clarified the prevalence of comorbid mood disorders in substance-dependent individuals, overturning previous assumptions that depression in these patients is simply an artifact of intoxication and/or withdrawal, therefore requiring no treatment. However, our understanding of the bidirectional relationships between mood and substance use disorders in terms of their course(s) of illness and prognoses remains limited. Like-wise, strikingly little treatment research exists to guide clinical decision making in co-occurring mood and substance use disorders, given their high prevalence and public health burden. Here we overview what is known and the salient gaps of knowledge where data might enhance diagnosis and treatment of these complicated patients.
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Affiliation(s)
- Bryan K Tolliver
- Addiction Sciences Division, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Raymond F Anton
- Addiction Sciences Division, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
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Chan P, Yomen K, Turcios J, Richman M. Prescription for antidepressant in reducing future alcohol-related readmission in patients suffering from depression and alcohol use disorder: a retrospective medical record review. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2015; 10:48. [PMID: 26690941 PMCID: PMC4687098 DOI: 10.1186/s13011-015-0045-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 12/16/2015] [Indexed: 12/13/2022]
Abstract
Background Patients suffering from major depressive disorder are more likely to suffer from alcohol use disorder. The data is inconclusive for the effectiveness of antidepressant treatment of patients suffering from both illnesses in regards to improving sobriety and reducing alcohol-related healthcare expenses such as hospitalizations. The objective of this study is to determine if a new prescription of an antidepressant upon inpatient discharge is associated with a reduction in the number of future acute alcohol-related hospital readmissions to the same institution in patients suffering from major depressive disorder and alcohol-use disorder. Methods A retrospective, medical record review study was conducted at a publicly-supported hospital in Sylmar, CA. A query was performed for adult patients admitted between 1/1/2005–12/31/2013 who had ICD-9 codes for both alcohol-use disorder and depression. Index admission was the first hospitalization in which the patient was currently consuming alcohol and had depression as identified by physician documentation as a problem. Acute alcohol-related admissions were those for alcohol intoxication or withdrawal (indicating current alcohol use). Patients were excluded if they were receiving an antidepressant on index admission, <18 years old, no patient data available, or not currently consuming alcohol; 139 patients met inclusion criteria. Multivariate logistical regression analysis was performed on the primary predictive variable of discharge prescription of an antidepressant along with other independent variables for alcohol readmissions: homelessness, family history of alcohol use disorder, and smoking. Results Discharging patients with a prescription of an antidepressant was not associated with a reduction in acute alcohol-related readmission. There was no difference in acute alcohol-related readmissions between patients discharged with (44.6 %) versus without (47.0 %) a prescription for an antidepressant (p = 0.863). The median number of days between index admission and first readmission for those discharged on an antidepressant was 141 days while those who were not was 112 days (p = 0.284). Conclusion Discharging patients suffering from both alcohol-use disorder and major depressive disorder with a prescription for an antidepressant is not associated with a reduction in future readmissions, nor significantly increase the number of days to readmission. The study does not support the concept of antidepressants in reducing acute alcohol-related readmissions.
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Affiliation(s)
- Patrick Chan
- Western University of Health Sciences, 309 E. 2nd St, Pomona, CA, 91766, USA.
| | - Katie Yomen
- University of California Los Angeles Medical Center, 757 Westwood Plaza, Room B531, Los Angeles, CA, USA.
| | - Jennifer Turcios
- Kaiser Permanente Baldwin Park, 1011 Baldwin Park Blvd, Baldwin Park, CA, USA.
| | - Mark Richman
- Department of Emergency Medicine, North Shore-LIJ Long Island Jewish Medical Center, 270-05 76th Ave, New Hyde Park, NY, 11040, USA.
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Pharmacogenetics of alcohol use disorders and comorbid psychiatric disorders. Psychiatry Res 2015; 230:121-9. [PMID: 26455758 DOI: 10.1016/j.psychres.2015.09.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 08/04/2015] [Accepted: 09/10/2015] [Indexed: 11/21/2022]
Abstract
Alcohol use disorders (AUDs) represent a significant health burden worldwide. Currently, there are three medications approved by the U.S. Food and Drug Administration for the treatment of AUDs, and other drugs are being prescribed off-label for this purpose. However, response rates for pharmacologic treatment are low, and extant research suggests that treatment effects may partially depend on genetic factors. Personalized medicine, or using a patient's genetics and/or personal history to determine efficacy of treatment prior to prescription, is an emerging tool that will help clinicians treat their patients more effectively and safely. This review systematically discusses current findings from AUD pharmacotherapy trials examining disulfiram, acamprosate, naltrexone, the injectable naltrexone, and topiramate. Furthermore, it presents pharmacogenetics findings associated with these medications in an attempt to further the field of personalized medicine. Research from trials examining AUDs and comorbid major depressive disorder and anxiety disorders is also presented, and pharmacogenetic findings for these treatments are discussed. Lastly, the authors comment on the present and future states of the field of personalized medicine for AUD.
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Acceptance and Commitment Therapy in the Treatment of Alcohol Use Disorder and Comorbid Affective Disorder: A Pilot Matched Control Trial. Behav Ther 2015; 46:717-28. [PMID: 26520216 DOI: 10.1016/j.beth.2015.05.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 05/06/2015] [Accepted: 05/15/2015] [Indexed: 11/21/2022]
Abstract
This study examined whether acceptance and commitment therapy (ACT) enhances treatment as usual (TAU) in improving treatment outcomes in patients with alcohol use disorder (AUD) and comorbid affective disorder. Fifty-two participants were included in the study, of whom 26 were patients with AUD and either depression or bipolar disorder treated with ACT group therapy in parallel with TAU (inpatient integrated treatment) and 26 were matched controls who had received TAU alone. Drinking and craving outcomes were total alcohol abstinence, cumulative abstinence duration (CAD) and Obsessive Compulsive Drinking Scale (OCDS) scores at 3 and 6 months postintervention. Affective and anxiety outcomes were Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI) and Young Mania Rating Scale (YMRS) scores at these follow-ups. Baseline demographic and clinical characteristics were similar in both groups. Retention rates were high: 100% of the ACT group were followed up at 3 and 6 months; 92.3% and 84.6% of the TAU alone group were followed up at 3 and 6 months, respectively. Patients in the ACT group reported significantly higher CAD at 3 and 6 months, significantly lower BDI and BAI scores at 3 and 6 months, and significantly lower OCDS scores at 3 months, than those who received only TAU. No other significant differences in treatment outcomes were found between the groups. ACT provides added benefit to TAU in improving drinking, craving, depression and anxiety outcomes in patients with AUD and comorbid affective disorder. Most treatment improvements were sustained over a 6-month follow-up period.
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Foulds JA, Adamson SJ, Boden JM, Williman JA, Mulder RT. Depression in patients with alcohol use disorders: Systematic review and meta-analysis of outcomes for independent and substance-induced disorders. J Affect Disord 2015; 185:47-59. [PMID: 26143404 DOI: 10.1016/j.jad.2015.06.024] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 06/11/2015] [Accepted: 06/14/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND In patients with an alcohol use disorder, depression is commonly categorised as independent (ID) or substance-induced (SID). It is not established whether these conditions respond differently to treatment. METHODS MEDLINE, Embase and Cochrane databases from 1980 to 2014 were searched for studies on alcohol use disorders with coexisting depressive symptoms. Meta-analyses were conducted using random effects models, to derive pooled effect estimates of the change in depression during treatment and the effect of antidepressant therapy. RESULTS Twenty-two studies met inclusion criteria for the review, of which 11/22 were included in the meta-analysis. All studies reported a large improvement in depression symptom score, most of which occurred within the first 3-6 weeks of treatment. The amount of improvement during follow up was similar in studies on ID in comparison to those in undifferentiated depression. Evidence on the outcome for SID was limited. The effect size of antidepressant therapy compared to placebo was 0.25 (0.06, 0.44) for ID and 0.08 (-0.31, 0.47) for SID or undifferentiated depression. LIMITATIONS Few studies examined the natural history and treatment response of SID. There was heterogeneity between studies, which was partly explained by baseline depression severity. CONCLUSIONS Treatment for depression co-occurring with an alcohol use disorder is associated with a large early improvement in depression, even if depression is believed to be independent of drinking. The effect of antidepressant therapy on depression in patients with alcohol use disorders is modest, with stronger evidence in ID.
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Affiliation(s)
- James A Foulds
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand.
| | - Simon J Adamson
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Joseph M Boden
- Christchurch Health and Development Study, University of Otago, Christchurch, New Zealand
| | - Jonathan A Williman
- Biostatistics and Computational Biology, Department of Public Health and General Practise, University of Otago, Christchurch, New Zealand
| | - Roger T Mulder
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
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Charney DA, Heath LM, Zikos E, Palacios-Boix J, Gill KJ. Poorer Drinking Outcomes with Citalopram Treatment for Alcohol Dependence: A Randomized, Double-Blind, Placebo-Controlled Trial. Alcohol Clin Exp Res 2015. [PMID: 26208048 DOI: 10.1111/acer.12802] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Previous research on the use of selective serotonin reuptake inhibitors (SSRIs) as a treatment for alcohol dependence has yielded mixed results. Depression has been shown to be a predictor of relapse and poor outcome following treatment, and it has been hypothesized that SSRIs would be beneficial in reducing drinking in depressed alcohol-dependent individuals. This randomized, double-blind, placebo-controlled trial was designed to test the effects of citalopram on treatment outcomes among alcohol-dependent individuals with and without depression. METHODS Two hundred and sixty-five patients meeting criteria for a DSM-IV diagnosis of alcohol abuse or dependence were randomly assigned to receive placebo or citalopram 20 mg per day for the first week, followed by 40 mg per day from weeks 2 through 12. All patients received a standard course of treatment consisting of weekly individual and group psychotherapy. Participants were reassessed at 12 weeks, including dropouts from both treatment groups to determine rates of abstinence, changes in alcohol use, addiction severity, depressive symptoms, and psychiatric status. RESULTS Citalopram provided no advantage over placebo in terms of treatment outcomes, and for some measures, citalopram produced poorer outcomes. Patients in the citalopram group had a higher number of heavy drinking days throughout the trial, and smaller changes in frequency and amount of alcohol consumption at 12 weeks. There was no influence of depression severity on outcomes in either medication group. Survival analyses also indicated no differences between depressed and nondepressed patients in the citalopram group for time to first slip or relapse. A diagnosis of personality disorder was associated with poorer treatment responses overall, regardless of treatment condition. CONCLUSIONS This trial does not support the use of citalopram in the treatment of alcohol dependence. The results suggest that the use of SSRIs among depressed and nondepressed alcohol-dependent individuals early in recovery, prior to the onset of abstinence, may be contraindicated.
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Affiliation(s)
- Dara A Charney
- Addictions Unit, McGill University Health Centre, Montreal, Quebec, Canada.,Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Laura M Heath
- Addictions Unit, McGill University Health Centre, Montreal, Quebec, Canada
| | - Eugenia Zikos
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Jorge Palacios-Boix
- Addictions Unit, McGill University Health Centre, Montreal, Quebec, Canada.,Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Kathryn J Gill
- Addictions Unit, McGill University Health Centre, Montreal, Quebec, Canada.,Department of Psychiatry, McGill University, Montreal, Quebec, Canada
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Marcinkiewcz CA. Serotonergic Systems in the Pathophysiology of Ethanol Dependence: Relevance to Clinical Alcoholism. ACS Chem Neurosci 2015; 6:1026-39. [PMID: 25654315 DOI: 10.1021/cn5003573] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Alcoholism is a progressive brain disorder that is marked by increased sensitivity to the positive and negative reinforcing properties of ethanol, compulsive and habitual use despite negative consequences, and chronic relapse to alcohol drinking despite repeated attempts to reduce intake or abstain from alcohol. Emerging evidence from preclinical and clinical studies implicates serotonin (5-hydroxytryptamine; 5-HT) systems in the pathophysiology of alcohol dependence, suggesting that drugs targeting 5-HT systems may have utility in the treatment of alcohol use disorders. In this Review, we discuss the role of 5-HT systems in alcohol dependence with a focus on 5-HT interactions with neural circuits that govern all three stages of the addiction cycle. We attempt to clarify how 5-HT influences circuit function at these different stages with the goal of identifying neural targets for pharmacological treatment of this debilitating disorder.
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Affiliation(s)
- Catherine A. Marcinkiewcz
- Bowles Center for
Alcohol
Studies, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, United States
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A randomized trial of combined citalopram and naltrexone for nonabstinent outpatients with co-occurring alcohol dependence and major depression. J Clin Psychopharmacol 2015; 35:143-9. [PMID: 25679122 DOI: 10.1097/jcp.0000000000000287] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Despite the high rate of co-occurrence of major depression and alcohol dependence, the role of pharmacotherapy in their treatment remains unclear. In the new era of naltrexone for alcohol dependence, it is notable that only 1 study to date has examined the efficacy of antidepressant medication prescribed concurrently with naltrexone. We aimed to determine whether combining naltrexone with citalopram produced better treatment outcomes than naltrexone alone in patients with co-occurring alcohol dependence and depression, and to investigate whether either sex or depression type (independent or substance-induced depression) moderated treatment response. Participants were 138 depressed alcohol-dependent adults who were not required to be abstinent at the commencement of the trial. They were randomized to 12 weeks of citalopram or placebo, plus naltrexone and clinical case management. Treatment was well attended, and medications were reasonably well tolerated with high adherence rates. Substantial improvements in both mood and drinking occurred in both groups, with no significant differences between groups on any of the mood or drinking outcome measures, whether or not other variables were controlled for. No interaction effect was found for independent/substance-induced depression status, whereas there was a marginal effect found by sex, with greater improvement in 1 drinking outcome measure (percent days abstinent) in women taking citalopram. These findings suggest that citalopram is not a clinically useful addition to naltrexone and clinical case management in this treatment population. Independent/substance-induced depression status did not predict treatment response. Findings for sex were equivocal.
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31
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Mendelevich VD. Accuracy of the choice of the dependence syndrome treatment: evidence-based addictology against clinical practice. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:59-63. [DOI: 10.17116/jnevro20151154259-63] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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The administration of atomoxetine during alcohol deprivation induces a time-limited increase in alcohol consumption after relapse. Int J Neuropsychopharmacol 2014; 17:1905-10. [PMID: 25025529 DOI: 10.1017/s146114571400087x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The administration of selective serotonin reuptake inhibitors (SSRIs) typically used as antidepressants increases alcohol consumption after an alcohol deprivation period in rats. However, the appearance of this effect after the treatment with selective noradrenaline reuptake inhibitors (SNRIs) has not been studied. In the present work we examined the effects of a 15-d treatment with the SNRI atomoxetine (1, 3 and 10 mg/kg, i.p.) in male rats trained to drink alcohol solutions in a 4-bottle choice test. The treatment with atomoxetine (10 mg/kg, i.p.) during an alcohol deprivation period increased alcohol consumption after relapse. This effect only lasted one week, disappearing thereafter. Treatment with atomoxetine did not cause a behavioral sensitized response to a challenge dose of amphetamine (1.5 mg/kg, i.p.), indicating the absence of a supersensitive dopaminergic transmission. This effect is markedly different from that of SSRI antidepressants that produced both long-lasting increases in alcohol consumption and behavioral sensitization. Clinical implications are discussed.
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Sacharczuk M, Lesniak A, Lipkowski AW, Korostynski M, Przewlocki R, Sadowski B. Association between the A107V substitution in the δ-opioid receptors and ethanol drinking in mice selected for high and low analgesia. Addict Biol 2014; 19:643-51. [PMID: 23301597 DOI: 10.1111/adb.12030] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Experimental evidence suggests that endogenous opioids play an important role in the development of ethanol addiction. In this study, we employed two mouse lines divergently bred for opioid-mediated stress-induced analgesia. In comparison with HA (high analgesia line) mice, LA (low analgesia line) mice, having lower opioid receptor system activity, manifest enhanced basal as well as stress-induced ethanol drinking. Here, we found that recently discovered C320T transition in exon 2 of the δ-opioid receptor gene (EU446125.1), which results in an A107V substitution (ACA23171.1), leads to higher ethanol preference in CT mice compared with CC homozygotes. This genetic association is particularly evident under chronic mild stress (CMS) conditions. The interaction between stress and ethanol intake was significantly stronger in HA than in LA mice. Ethanol almost completely attenuated the pro-depressive effect of CMS (assessed with the tail suspension test) in both the CC and CT genotypes in the HA line. In the LA mice, a lack of response to ethanol was observed in the CC genotype, whereas ethanol consumption strengthened depressive-like behaviours in CT individuals. Our results suggest that constitutively active A107V substitution in δ-opioid receptors may be involved in stress-enhanced vulnerability to ethanol abuse and in the risk of ethanol dependence.
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Affiliation(s)
- Mariusz Sacharczuk
- Department of Molecular Cytogenetics, Institute of Genetics and Animal Breeding, Polish Academy of Sciences, Poland
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Rorick-Kehn LM, Witkin JM, Statnick MA, Eberle EL, McKinzie JH, Kahl SD, Forster BM, Wong CJ, Li X, Crile RS, Shaw DB, Sahr AE, Adams BL, Quimby SJ, Diaz N, Jimenez A, Pedregal C, Mitch CH, Knopp KL, Anderson WH, Cramer JW, McKinzie DL. LY2456302 is a novel, potent, orally-bioavailable small molecule kappa-selective antagonist with activity in animal models predictive of efficacy in mood and addictive disorders. Neuropharmacology 2014; 77:131-44. [DOI: 10.1016/j.neuropharm.2013.09.021] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 09/10/2013] [Accepted: 09/13/2013] [Indexed: 11/29/2022]
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Abstract
Addictions are prevalent psychiatric disorders that confer remarkable personal and social burden. Despite substantial evidence for their moderate, yet robust, heritability (approx. 50%), specific genetic mechanisms underlying their development and maintenance remain unclear. The goal of this selective review is to highlight progress in unveiling the genetic underpinnings of addiction. First, we revisit the basis for heritable variation in addiction before reviewing the most replicable candidate gene findings and emerging signals from genomewide association studies for alcohol, nicotine and cannabis addictions. Second, we survey the modest but growing field of neurogenetics examining how genetic variation influences corticostriatal structure, function, and connectivity to identify neural mechanisms that may underlie associations between genetic variation and addiction. Third, we outline how extant genomic findings are being used to develop and refine pharmacotherapies. Finally, as sample sizes for genetically informed studies of addiction approach critical mass, we posit five exciting possibilities that may propel further discovery (improved phenotyping, rare variant discovery, gene-environment interplay, epigenetics, and novel neuroimaging designs).
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Anton RF, Schacht JP, Book SW. Pharmacologic treatment of alcoholism. HANDBOOK OF CLINICAL NEUROLOGY 2014; 125:527-42. [PMID: 25307594 DOI: 10.1016/b978-0-444-62619-6.00030-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Progress in understanding the neuroscience of addiction has significantly advanced the development of more efficacious medications for the treatment of alcohol use disorders (AUD). While several medications have been approved by regulatory bodies around the world for the treatment of AUD, they are not universally efficacious. Recent research has yielded improved understanding of the genetics and brain circuits that underlie alcohol reward and its habitual use. This research has contributed to pharmacogenetic studies of medication response, and will ultimately lead to a more "personalized medicine" approach to AUD pharmacotherapy. This chapter summarizes work on clinically available medications (both approved by regulatory bodies and investigational) for the treatment of alcohol dependence, as well as the psychiatric disorders that are commonly comorbid with AUD. Studies that have evaluated genetic influences on medication response and those that have employed neuroimaging to probe mechanisms of medication action or response are highlighted. Finally, new targets discovered in animal models for possible pharmacologic intervention in humans are overviewed and future directions in medications development provided.
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Affiliation(s)
- Raymond F Anton
- Center for Drug and Alcohol Programs, Alcohol Research Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA.
| | - Joseph P Schacht
- Center for Drug and Alcohol Programs, Alcohol Research Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Sarah W Book
- Center for Drug and Alcohol Programs, Alcohol Research Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
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Stephen Rich J, Martin PR. Co-occurring psychiatric disorders and alcoholism. HANDBOOK OF CLINICAL NEUROLOGY 2014; 125:573-588. [PMID: 25307597 DOI: 10.1016/b978-0-444-62619-6.00033-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Alcohol use disorder (AUD), a term that comprises both alcohol abuse and alcohol dependence, is a highly prevalent psychiatric disorder. Over 50% of treated AUD patients also suffer from other psychiatric disorder(s). Detailed study has revealed disorders across multiple psychiatric domains with rates of co-occurrence far greater than chance, suggesting a synergistic relationship. The basis of this synergy is explored along with its multiple forms, including behavioral and neurobiologic. Specific topics include the predisposition to both AUD and co-occurring psychopathology, the vulnerability to environmental risk factors that exacerbate these predispositions, and the nature of reinforcement in acute intoxication. Co-occurrence can also modify and exacerbate the neuroadaptations underpinning chronic dependence and relapse, the manifestations of acute and protracted withdrawal, emergence of medical and psychiatric complications, and ultimately the potential for relapse. The outcomes of co-occurrence as well as the unique impact it has on proper treatment are also discussed. Throughout, the significance of recognizing co-occurrence is emphasized since, both neurobiologically and clinically, the synergies between co-occurring disorders yield a result far more complex than a mere sum of the component disorders.
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Affiliation(s)
- J Stephen Rich
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Peter R Martin
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA.
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Raby WN, Rubin EA, Garawi F, Cheng W, Mason E, Sanfilippo L, Lord S, Bisaga A, Aharonovich E, Levin F, McDowell D, Nunes EV. A randomized, double-blind, placebo-controlled trial of venlafaxine for the treatment of depressed cocaine-dependent patients. Am J Addict 2013; 23:68-75. [PMID: 24313244 DOI: 10.1111/j.1521-0391.2013.12065.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 02/04/2013] [Accepted: 02/19/2013] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE This study tested the hypothesis that the antidepressant venlafaxine would be an effective treatment for cocaine abusers with concurrent depressive disorders. METHODS This was a randomized, 12-week, double-blind, placebo-controlled trial of outpatients (N = 130) meeting DSM-IIIR criteria for cocaine dependence and major depression or dysthymia (by SCID interview). Participants were treated with venlafaxine, up to 300 mg/day versus placebo. All patients received weekly individual manual-guided relapse prevention therapy. Weekly outcome measures included Clinical Global Impression Scale (CGI), self-reported cocaine use, urine toxicology and the Hamilton Depression Scale (Ham-D). RESULTS Mood response, defined as a 50% reduction in the Ham-D between randomization and end of study, was 41% (26/64) on venlafaxine, and 33% (22/66) on placebo (p = .39). Measures of depression (Ham-D and CGI) improved more rapidly on venlafaxine than placebo, but these differences disappeared by weeks 6-8. Cocaine outcomes did not differ between treatment groups, and the proportion of patients achieving three or more consecutive weeks of urine-confirmed abstinence was low (venlafaxine: 16%; placebo: 15%). Reduction in cocaine use was associated with mood response. CONCLUSIONS Overall, venlafaxine was not superior to placebo on either mood or cocaine use outcomes. Mood improvement was associated with improvement in cocaine use. However, placebo mood response was only moderate, and the proportion of patients achieving sustained abstinence was low. This suggests that the subgroup of cocaine-dependent patients with depressive disorders is relatively treatment resistant, and that further research is needed to improve outcomes for these patients.
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Affiliation(s)
- Wilfrid Noel Raby
- Division on Substance Abuse, New York State Psychiatric Institute, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, New York
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Pettinati HM, O’Brien CP, Dundon WD. Current status of co-occurring mood and substance use disorders: a new therapeutic target. Am J Psychiatry 2013; 170:23-30. [PMID: 23223834 PMCID: PMC3595612 DOI: 10.1176/appi.ajp.2012.12010112] [Citation(s) in RCA: 155] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Mood and substance use disorders commonly co-occur, yet there is little evidence-based research to guide the pharmacologic management of these comorbid disorders. The authors review the existing empirical findings, some of which may call into question current clinical pharmacotherapy practices for treating co-occurring mood and substance use disorders. The authors also highlight knowledge gaps that can serve as a basis for future research. The specific mood disorders reviewed are bipolar and major depressive disorders (either one co-occurring with a substance use disorder). Overall, findings from the relatively small amount of available data indicate that pharmacotherapy for managing mood symptoms can be effective in patients with substance dependence, although results have not been consistent across all studies. Also, in most studies, medications for managing mood symptoms did not appear to have an impact on the substance use disorder. In a recent trial for comorbid major depression and alcohol dependence, combination treatment with a medication for depression and another for alcohol dependence was found to reduce depressive symptoms and excessive drinking simultaneously. However, research has only begun to address optimal pharmacologic management of co-occurring disorders. In addition, current clinical treatment for alcohol and drug dependence often excludes new pharmacotherapies approved by the U.S. Food and Drug Administration for treating certain types of addiction. With new data becoming available, it appears that we need to revisit current practice in the pharmacological management of co-occurring mood and substance use disorders.
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Warnock KT, Yang AR, Yi HS, June HL, Kelly T, Basile AS, Skolnick P, June HL. Amitifadine, a triple monoamine uptake inhibitor, reduces binge drinking and negative affect in an animal model of co-occurring alcoholism and depression symptomatology. Pharmacol Biochem Behav 2012; 103:111-8. [PMID: 22884707 PMCID: PMC3537915 DOI: 10.1016/j.pbb.2012.07.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 07/25/2012] [Accepted: 07/27/2012] [Indexed: 01/08/2023]
Abstract
The co-occurrence of alcoholism and depression is highly prevalent and difficult to treat. In an animal model of binge drinking that exhibits abstinence-induced behaviors reminiscent of negative affective states, the triple monoamine uptake inhibitor, amitifadine, produced a selective, dose dependent attenuation of binge drinking. Amitifadine also reversed abstinence-induced increases in the intracranial self-stimulation threshold, a model of anhedonia, and immobility in the forced swim test, reflecting behavioral despair. In view of the safety profile of amitifadine in humans, including low risk for weight gain, lack of sexual side effects, and low potential for abuse, we hypothesize that amitifadine will be effective in treating co-occurring alcoholism and depression.
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Affiliation(s)
- Kaitlin T. Warnock
- Neuropsychopharmacology Laboratory, Department of Psychiatry and Behavioral Sciences, Howard University College of Medicine, Washington, DC 20060, USA
| | - Andrew R.S.T. Yang
- Neuropsychopharmacology Laboratory, Department of Psychiatry and Behavioral Sciences, Howard University College of Medicine, Washington, DC 20060, USA
| | - Heon S. Yi
- Neuropsychopharmacology Laboratory, Department of Psychiatry and Behavioral Sciences, Howard University College of Medicine, Washington, DC 20060, USA
| | - Harry L. June
- Neuropsychopharmacology Laboratory, Department of Psychiatry and Behavioral Sciences, Howard University College of Medicine, Washington, DC 20060, USA
| | - Tim Kelly
- Neuropsychopharmacology Laboratory, Department of Psychiatry and Behavioral Sciences, Howard University College of Medicine, Washington, DC 20060, USA
| | | | - Phil Skolnick
- DOV Pharmaceutical, Inc., Somerset, N.J., 08873, USA
| | - Harry L. June
- Neuropsychopharmacology Laboratory, Department of Psychiatry and Behavioral Sciences, Howard University College of Medicine, Washington, DC 20060, USA
- Department of Pharmacology, Howard University College of Medicine Washington, DC 20060, USA
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Yang ARST, Yi HS, Warnock KT, Mamczarz J, June HL, Mallick N, Krieter PA, Tonelli L, Skolnick P, Basile AS, June HL. Effects of the triple monoamine uptake inhibitor DOV 102,677 on alcohol-motivated responding and antidepressant activity in alcohol-preferring (P) rats. Alcohol Clin Exp Res 2011; 36:863-73. [PMID: 22150508 DOI: 10.1111/j.1530-0277.2011.01671.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Concurrent inhibitors of dopamine, norepinephrine, and serotonin uptake have been proposed as novel antidepressants. Given the high comorbidity between alcoholism and depression, we evaluated the activity of DOV 102,677 (DOV) on alcohol-maintained responding and performance in the forced swim test (FST), a model of antidepressant (AD) activity, using alcohol-preferring (P) rats. METHODS Following training to lever press for either alcohol (10% v/v) or sucrose (3, 2%, w/v) on a fixed-ratio 4 (FR4) schedule, DOV (1.56 to 50 mg/kg; PO) was given 25 minutes or 24 hours prior to evaluation. The effects of DOV (12.5 to 50 mg/kg; PO) in the FST were evaluated 25 minutes posttreatment. RESULTS DOV (6.25 to 50 mg/kg) dose-dependently reduced alcohol-maintained responding by 59 to 88% at 25 minutes posttreatment, without significantly altering sucrose responding. The reduction in alcohol responding (44% at 50 mg/kg) was sustained for up to 120 hours after a single dose. Administration of a single dose of DOV (25, 50 mg/kg) 24 hours before testing suppressed alcohol responding for 48 hours by 59 to 62%. DOV (12.5 to 50 mg/kg) also dose-dependently reduced immobility of P rats in the FST. CONCLUSIONS DOV produces both prolonged and selective reductions of alcohol-motivated behaviors in P rats. The elimination kinetics of DOV suggests that its long duration of action may be due to an active metabolite. DOV also produced robust AD-like effects in P rats. We propose that DOV may be useful in treating comorbid alcoholism and depression in humans.
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Affiliation(s)
- Andrew R S T Yang
- Department of Psychiatry and Behavioral Sciences, Howard University College of Medicine, Washington, DC, USA
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Hirschtritt ME, Pagano ME, Christian KM, McNamara NK, Stansbrey RJ, Lingler J, Faber JE, Demeter CA, Bedoya D, Findling RL. Moderators of fluoxetine treatment response for children and adolescents with comorbid depression and substance use disorders. J Subst Abuse Treat 2011; 42:366-72. [PMID: 22116008 DOI: 10.1016/j.jsat.2011.09.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Revised: 09/16/2011] [Accepted: 09/19/2011] [Indexed: 11/29/2022]
Abstract
Our recent 8-week, randomized, placebo-controlled trial of fluoxetine in adolescents (ages 12-17 years) with comorbid depression and substance use disorder (SUD) did not detect a significant antidepressant treatment effect. The purpose of this secondary analysis was to explore moderators of the effect of fluoxetine in this sample. Static moderators measured at baseline were depression chronicity and hopelessness severity; time-varying moderators measured at baseline and weekly during the 8-week trial period were alcohol and marijuana use severity. Treatment effects on depression outcomes were examined among moderating subgroups in random effects regression models. Subjects assigned to fluoxetine treatment with chronic depression at baseline (p = .04) or no more than moderate alcohol use during the trial (p = .04) showed significantly greater decline in depression symptoms in comparison to placebo-assigned subgroups. The current analysis suggests that youth with chronic depression and no more than moderate alcohol consumption are likely to respond better to treatment with fluoxetine compared with placebo than youth with transient depression and heavy alcohol use.
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Affiliation(s)
- Matthew E Hirschtritt
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, 9500 Euclid Avenue, NA21, Cleveland, OH 44195, USA.
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Balaratnasingam S, Janca A. Combining sertraline and naltrexone in the treatment of adults with comorbid depression and alcohol dependence. Curr Psychiatry Rep 2011; 13:245-7. [PMID: 21468673 DOI: 10.1007/s11920-011-0198-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Sivasankaran Balaratnasingam
- School of Psychiatry and Clinical Neurosciences, Community, Culture, and Mental Health Unit, University of Western Australia; Kimberley Mental Health and Drug Service, Australia.
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Hobbs JDJ, Kushner MG, Lee SS, Reardon SM, Maurer EW. Meta-analysis of supplemental treatment for depressive and anxiety disorders in patients being treated for alcohol dependence. Am J Addict 2011; 20:319-29. [PMID: 21679263 DOI: 10.1111/j.1521-0391.2011.00140.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Approximately half of those receiving treatment for an alcohol use disorder (AUD) also suffer with an anxiety or depressive (internalizing) disorder. Because all internalizing disorders mark a poor alcohol treatment outcome, it seems reasonable to supplement AUD treatment with a psychiatric intervention when these disorders co-occur with AUD. However, this conclusion may be faulty given that the various possible interrelationships between AUD and internalizing disorders do not uniformly imply a high therapeutic yield from this approach. Unfortunately, the studies conducted to date have been too few and too small to resolve this important clinical issue with confidence. Therefore, we used a meta-analytic method to synthesize the effects from published randomized controlled trials examining the impact of supplementing AUD treatment with a psychiatric treatment for co-occurring internalizing disorder (N = 15). We found a pooled effect size (d) of .32 for internalizing outcomes and .22 for a composite of alcohol outcomes; however, the alcohol outcomes effect sizes were greater than this for some specific outcome domains. Subgroups that differed in terms of internalizing outcomes included treatment type (medication vs. cognitive behavioral therapy) and treatment focus (anxiety vs. depression). There was also a trend for the studies with better internalizing disorder outcomes to have better alcohol outcomes. These results indicate that clinical outcomes (both psychiatric and alcohol-related) could be somewhat improved by supplementing AUD treatment with psychiatric treatment for co-occurring internalizing disorder.
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Affiliation(s)
- Jennifer D J Hobbs
- Department of Psychiatry, University of Minnesota, Minneapolis, 55454, USA
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Abstract
OBJECTIVE To summarize published data on pharmacologic treatments for alcohol dependence alone and in combination with brief psychosocial therapies that may be feasible for primary care and specialty medical settings. METHODS We conducted electronic searches of published original research articles and reviews in MEDLINE, SCOPUS, CINAHL, Embase, and PsychINFO. In addition, hand searches of reference lists of review articles, supplemental searches of internet references and contacts with experts in the field were conducted. Randomized controlled studies published between January 1960 and August 2010 that met our inclusion/exclusion criteria were included. RESULTS A total of 85 studies, representing 18,937 subjects, met our criteria for inclusion. The evidence base for oral naltrexone (6% more days abstinent than placebo in the largest study) and topiramate (prescribed off-label) (e.g., 26.2% more days abstinent than placebo in a recent study) is positive but modest. Acamprosate shows modest efficacy with recently abstinent patients, with European studies showing better results than U.S. ones. The evidence-base for disulfiram is equivocal. Depot naltrexone shows efficacy (25% greater reduction in rate of heavy drinking vs. placebo, in one of the largest studies) in a limited number of studies. Some studies suggest that patients do better with extensive psychosocial treatments added to medications while others show that brief support can be equally effective. CONCLUSIONS Although treatment effects are modest, medications for alcohol dependence, in conjunction with either brief support or more extensive psychosocial therapy, can be effective in primary and specialty care medical settings.
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Affiliation(s)
- Peter M Miller
- Center for Drug and Alcohol Programs, Medical University of South Carolina, Charleston, SC 29425, USA.
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Farren CK, McElroy S. Predictive Factors for Relapse after an Integrated Inpatient Treatment Programme for Unipolar Depressed and Bipolar Alcoholics. Alcohol Alcohol 2010; 45:527-33. [DOI: 10.1093/alcalc/agq060] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
IMPORTANCE OF THE FIELD Alcoholism is a widespread disorder with substantial mortality and negative treatment outcomes. To date, few medications have been found to reduce relapse rates or drinking in alcohol-dependent patients. AREAS COVERED IN THIS REVIEW This review focuses on drugs that have been clinically tested for the treatment of alcohol dependence in clinical trials, pilot trials or which are considered to have a clinical perspective. For this purpose, a detailed Medline search was conducted on this issue. Although the neurochemical basis of alcoholism and the neuronal circuitry mediating its psychotropic effects have been explored in great detail in recent years, few drugs have emerged for the treatment of alcohol dependence, also because pharmaceutical companies have only a limited interest in this area of research. Acamprosate and the opioid antagonist naltrexone have been found to be effective, although data are mixed. A depot formula of naltrexone and the alternate opioid antagonist nalmefene have been studied in clinical trials and will presumably be introduced in the markets soon. Other emerging drugs are topiramate, novel acetaldehyde dehydrogenase (ALDH) inhibitors, baclofen, a combination therapy of gababentin and flumazenil and drugs targeting the cortitropin-releasing factor/neuropeptide Y mediated stress axis. WHAT THE READER WILL GAIN Insights on the neurochemical basis of alcohol dependence and possible targets of medications. TAKE HOME MESSAGE Acamprosate, naltrexone and the ALDH inhibitor disulfiram are proven medications for the treatment of alcohol dependence with modest efficacy. Novel alternate medications, a depot formulation of the opioid antagonist naltrexone and another oral opioid antagonist, nalmefene, are available now with good evidence for clinical efficacy. Novel ALDH inhibitors, antiepileptic drugs such as topiramate and drugs targeting the stress axis are currently among the most promising emerging drugs.
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Affiliation(s)
- Michael Soyka
- Psychiatric Hospital, University of Munich, Nussbaumstr. 7 80336 Munich, Germany.
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Pettinati HM, Oslin DW, Kampman KM, Dundon WD, Xie H, Gallis TL, Dackis CA, O’Brien CP. A double-blind, placebo-controlled trial combining sertraline and naltrexone for treating co-occurring depression and alcohol dependence. Am J Psychiatry 2010; 167:668-75. [PMID: 20231324 PMCID: PMC3121313 DOI: 10.1176/appi.ajp.2009.08060852] [Citation(s) in RCA: 172] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Empirical evidence has only weakly supported antidepressant treatment for patients with co-occurring depression and alcohol dependence. While some studies have demonstrated that antidepressants reduce depressive symptoms in individuals with depression and alcohol dependence, most studies have not found antidepressant treatment helpful in reducing excessive drinking in these patients. The authors provide results from a double-blind, placebo-controlled trial that evaluated the efficacy of combining approved medications for depression (sertraline) and alcohol dependence (naltrexone) in treating patients with both disorders. METHOD A total of 170 depressed alcohol-dependent patients were randomly assigned to receive 14 weeks of treatment with sertraline (200 mg/day [N=40]), naltrexone (100 mg/day [N=49]), the combination of sertraline plus naltrexone (N=42), or double placebo (N=39) while receiving weekly cognitive-behavioral therapy. RESULTS The sertraline plus naltrexone combination produced a higher alcohol abstinence rate (53.7%) and demonstrated a longer delay before relapse to heavy drinking (median delay=98 days) than the naltrexone (abstinence rate: 21.3%; delay=29 days), sertraline (abstinence rate: 27.5%; delay=23 days), and placebo (abstinence rate: 23.1%; delay=26 days) groups. The number of patients in the medication combination group not depressed by the end of treatment (83.3%) approached significance when compared with patients in the other treatment groups. The serious adverse event rate was 25.9%, with fewer reported with the medication combination (11.9%) than the other treatments. CONCLUSIONS More depressed alcohol-dependent patients receiving the sertraline plus naltrexone combination achieved abstinence from alcohol, had delayed relapse to heavy drinking, reported fewer serious adverse events, and tended to not be depressed by the end of treatment.
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Affiliation(s)
- Helen M. Pettinati
- Center for the Studies of Addiction, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA 19104
| | - David W. Oslin
- Center for the Studies of Addiction, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA 19104,Philadelphia Veterans Affairs Medical Center, Philadelphia, PA 19104
| | - Kyle M. Kampman
- Center for the Studies of Addiction, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA 19104
| | - William D. Dundon
- Center for the Studies of Addiction, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA 19104
| | - Hu Xie
- Center for the Studies of Addiction, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA 19104
| | - Thea L. Gallis
- Center for the Studies of Addiction, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA 19104
| | - Charles A. Dackis
- Center for the Studies of Addiction, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA 19104
| | - Charles P. O’Brien
- Center for the Studies of Addiction, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA 19104,Philadelphia Veterans Affairs Medical Center, Philadelphia, PA 19104
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Heffner JL, Tran GQ, Johnson CS, Barrett SW, Blom TJ, Thompson RD, Anthenelli RM. Combining motivational interviewing with compliance enhancement therapy (MI-CET): development and preliminary evaluation of a new, manual-guided psychosocial adjunct to alcohol-dependence pharmacotherapy. J Stud Alcohol Drugs 2010; 71:61-70. [PMID: 20105415 PMCID: PMC2815064 DOI: 10.15288/jsad.2010.71.61] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Revised: 06/26/2009] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Psychosocial interventions that are practical, transportable, and effective in promoting treatment adherence and efficacy are greatly needed in both research and clinical settings involving alcohol-dependence pharmacotherapy. In this article, we describe the development and preliminary evaluation of an integrative treatment blending motivational interviewing and compliance enhancement therapy (MI-CET) as a means of enhancing adherence and retention in an ongoing clinical trial. METHOD Medication adherence, session attendance, and study completion rates were examined for 121 treatment-seeking, alcohol-dependent adults participating in a randomized clinical trial of citalopram (n = 81) versus placebo (n = 40). All participants received the manual-guided MI-CET intervention as an adjunct to pharmacotherapy. Preliminary adherence and retention data for this trial were compared with data from prior studies involving treatment for alcohol dependence with a selective serotonin reuptake inhibitor. RESULTS High rates of medication adherence (79% of citalopram and 91% of placebo completers took > or = 80% of doses), session attendance (average of 90% for citalopram and 93% for placebo groups), and study completion (81% for citalopram and 88% for placebo groups) were obtained in the present study using MI-CET. These rates were at least comparable to or were, in some cases, 20%-30% higher than rates obtained in the comparison trials. CONCLUSIONS These results suggest that MI-CET is feasible as a psychosocial adjunct to alcohol-dependence pharmacotherapy. Given its strengths as a clinical and research intervention (e.g., practicality, transportability), further evaluation of its efficacy is warranted.
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Affiliation(s)
- Jaimee L. Heffner
- Tri-State Tobacco and Alcohol Research Center, Department of Psychiatry, University of Cincinnati College of Medicine, UC Reading Campus, 2120 E. Galbraith Road, Building A, Cincinnati, Ohio 45237
| | | | | | - Suzan Winders Barrett
- Tri-State Tobacco and Alcohol Research Center, Department of Psychiatry, University of Cincinnati College of Medicine, UC Reading Campus, 2120 E. Galbraith Road, Building A, Cincinnati, Ohio 45237
| | | | | | - Robert M. Anthenelli
- Tri-State Tobacco and Alcohol Research Center, Department of Psychiatry, University of Cincinnati College of Medicine, UC Reading Campus, 2120 E. Galbraith Road, Building A, Cincinnati, Ohio 45237
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Friedman ES, Wisniewski SR, Gilmer W, Nierenberg AA, Rush AJ, Fava M, Zisook S, Balasubramani GK, Trivedi MH. Sociodemographic, clinical, and treatment characteristics associated with worsened depression during treatment with citalopram: results of the NIMH STAR(*)D trial. Depress Anxiety 2009; 26:612-21. [PMID: 19382183 DOI: 10.1002/da.20568] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
CONTEXT Outcomes of antidepressant medication treatment for major depressive disorder include remission, response, and nonresponse. But nonresponse can include depression that worsened over the course of treatment, an outcome that has received scant attention. OBJECTIVE To describe baseline sociodemographic, clinical, and treatment characteristics associated with worsened depression during a trial of citalopram. DESIGN, PARTICIPANTS, AND SETTINGS: Open-label clinical trial of 2,876 adult outpatients seen in 18 primary and 23 psychiatric-care settings. INTERVENTION Citalopram was delivered using measurement-based care and flexible dosing with the aim of achieving symptom remission. Symptom and side effect ratings were obtained at each treatment visit. MAIN OUTCOME MEASURES Worsened depression was defined as an exit score >or=3 points above the pretreatment (baseline) score on the 16-item QIDS-SR. Baseline sociodemographic, clinical, and treatment characteristics were examined for association with worsened depression. RESULTS Of 2,864 outpatients who returned for >or=2 post baseline visits, 150 (5.2%) had worsened depression at study exit. Baseline characteristics independently associated with increased worsened depression included African-American race (OR=2.02), having less than a college education (OR=2.36), posttraumatic stress disorder (OR=1.78), drug abuse (OR=1.97), hypochondriasis (OR=2.74). Participants with worsened depression spent less time in treatment; had fewer treatment visits; exited the study sooner; had more frequent, intense, and burdensome adverse effects; and were more intolerant of medication. CONCLUSIONS The presence of certain baseline characteristics indicated a greater likelihood of worsened depression during antidepressant treatment. Patients with these characteristics should be monitored closely during treatment and may be candidates for more aggressive treatment.
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Affiliation(s)
- Edward S Friedman
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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